This article points out the well documented fact that increased
physical activity has clear-cut protective effect from all cause
mortality(1). Developing countries like India are also acknowledging such
facts and are issuing guidelines for the same so as to promote health care
of elderly even at primary health care level(2).

With development and prosperity the average individual age is
increasing which is attracting focus of governments and policy makers
towards growing need to cater to such population. The root cause of major
physical impairment in old age is physical inactivity and its
consequences, this fact need to be projected in a clear and concrete way
in the midst of general population specially the elderly and their
families.

The physician, individual concerned and community all should work in
synchronization towards promoting health and vitality to the elderly.
There needs to be greater involvement of elderly into accepting increasing
bodily movements as a part of life. Another area of concern will be ways
to protract such activity and devote greater manpower and political will
towards this often neglected but inevitable phase of life.

The increasing numbers of frail elderly patients certainly poses a
challenge for all parts of the healthcare landscape within the UK and
beyond. Whilst organisational change and modifications to where, when and
how we deliver care is important this must be underpinned by appropriate
education for doctors and allied healthcare professionals.

Much of this needs to be aimed at more junior staff, especially
medical students and junior doctors. Elderly care medicine has been
undervalued for too long and the complexities of older people have been
underestimated. Education therefore needs to be focussed on two main
areas:

1. An ability to understand complex medical conditions, the
interactions that these conditions have with each other and the
medications that can improve and worsen these problems. This must be
learnt in the context of the multi-disciplinary team and understand the
complex psycho-social dimensions that exist within the ageing community.

2. An understanding that over medicalisation of the health needs of
older people can be detrimental to both physical and psychological care,
in particular the understanding that just because we can investigate and
treat problems doesn't mean that we should. These decisions are complex
and should be made in conjunction with patients, their families and
independant advocates if patients lack capacity and family.

Changes to the care of older people must be made in a sustainable and
holistic way which have education as the foundation to ensure
modifications are successful.

Predicting prognosis in this older group of patients is complex due
to their highly variable health status, driven by their fundamentally
different prognosis to younger patients. We have published two recent
pieces on this theme, showing that firstly though there was an incremental
reduction in the use of evidence-based therapies for ACS (acute coronary
syndrome) with older age and that better survival was associated with
intensive management at all ages, this benefit was attenuated the older
the patient.(1) Secondly, higher troponin levels are associated with
increasing risk of mortality, but we found very high mortality rates in
older patients even at the lowest troponin values. There was an
attenuation of the prognostic value of troponins in older age and thus,
the prognostic value of troponins depends on patient age in ACS -
essentially, age is the biggest prognostic marker, and arguably markers we
use in younger patients are not as relevant in older patients.(2) Current
risk scores to guide aggressive management of coronary disease in the
older person perform poorly, over-estimating mortality and ignoring
morbidity, perhaps of more relevance to this age group.(3) In a population
of older adults, adjustment for 27 biological risk factors including co-
morbidity, social status, lifestyle and disease factors, cognition and
frailty substantially reduced the association between chronological age
and 5-year mortality (ages 80-84 years: unadjusted relative risk, 4.1;
adjusted relative risk, 1.7).(4)

As outcomes are influenced by both age and co-morbidity, is the under
-treatment of older people with ACS relative to younger patients thus
'appropriate'? Evidence suggests that risks associated with more intensive
management in older people may be related more to their greater co-
morbidity than age alone(5) and thus chronological age alone may not be
the best measure by which to plan clinical management in older people.
Trials also tend to focus on hard outcomes and also rarely take into
account wider prognostic measures such as disability, repeated
hospitalisation and return to independent living that are more relevant in
older people. Others have also written that sometimes following exacting
clincial guidelines that lead to more treatment may not be in the best
interests of the older patient.(6)

The ideal pathway in the older patient for example with an ACS should
not assume early intervention with revascularisation is the optimum
strategy (as is usually the case in the younger patient) but should be a
more holistic management strategy based upon thorough comprehensive
geriatric assessment. Frailty,(7) functional status, and social aspects of
care in the elderly are rarely included as clinical parameters (read wider
prognostic markers) in decisions pertaining to future care. Furthermore,
outcomes beyond survival need assessing, and ones of particular relevance
to the older patient.

Dear editor:
We read with great interest the paper by Bass et al[1] on the mnemonics of cholelithiatis in the november 2013 issue of PMJ.
The authors conclude that Family History should be considered as a predictive factor. We would like to share our own experience
on this matter.
We collected 173 consecutive patients diagnosed of cholelithiasis, inpatients and ambulatory care patients, during January
and February, 2014.
In all cases the diagnosis of biliary stones was established by an abdominal ultrasound or surgical confirmation.
Patients were interviewed on sex, age, parity, family history of cholelitiasis. Skin fair and the body mass index were determined
by our team.
Parity was considered positive when there was at least one born child. Fat was considered as such with a BMI of 25 or more.
A family history was considered positive if a first degree relative had been diagnosed or had surgery for cholelithiasis.
A total of 173 patients were included; with an age average of 50,16 +- 14 years and 79.8 % female. The frequency of each of
the 6 Fs studied are a)Fertility:95.7% ; b)Female: 97.8% ; c)Forty: 75.1% ; d)Fat: 69.9% ; e)Family History: 46.2%, f) Fair:
4%
(*Fertility: only females ; fat: excluded 69 patients with surgical confirmation)
According to our results, fertility, female gender, age above 40 years and an increased BMI were the 4 Fs that best predicted
cholelithiasis. In Peru, and particularly in Callao, where predominant skin phototypes are III, IV and V and fair skin is
very rarely found, the F of fair, should be disregarded[2]. Therefore, we agree with the authors that Family History should
also be considered as a predictive factor.
Conflict of Interest: None declared
REFERENCES
1. Bass G, Gilani SNS,Walsh TN.Validating the 5Fs mnemonic for cholelithiasis: time
to include family history. Postgrad Med J 2013;89:638-641.
2. Ramos C, Ramos M. Conocimientos, actitudes y practicas en fotoproteccion y fototipo cutaneo en asistentes a una campana
preventiva del cancer de piel. Callao-Peru. Febrero 2010.Dermatol Peru 2010;20(3):169-173

When Professor Weller and her colleagues speak of members of the team
being "on the same page"(1) no mention is made of the patient(or the
patient's advocate)(2) being also on the identical page. To facilitate the
inclusion of the patient in the team I have proposed the use of an
abbreviated patient-held health record which essentially documents the
problem list and the corresponding drug list, and this should be updated
each time the patient attends a healthcare facility(3). So as to mitigate
the risk of inadvertent adverse drug interactions, the community
pharmacist, too, needs to be on the same page as the patient. Accordingly,
each time new medication is prescribed, the patient should be advised to
take his abbreviated patient-held record with him so that he can spell out
to the pharmacist what his current medications are(4).
Finally, in recognition of the potential for the hierarchical structure to
generate "disastrous consequences"(1), patient-related correspondence from
secondary care to primary care must include a copy to the patient so that
the patient can compile his own medical file, which he can then carry with
him to complement the abbreviated patient-held record in the event of an
admission(here or overseas) to a hospital other than his usual hospital.
The patient can also refer to that medical file if he wants to correct
factual inaccuracies which sometimes creep into the correspondence. At a
stroke such measures would create a level playing field between the
patient and the healthcare team, thereby mitigating the risk of disastrous
consequences attributable to the hierarchical system.
References
(1)Weller J., Boyd M., Cumin D
Teams, tribes, and patient safety: overcoming the barriers to effective
teamwork in healthcare
Postgrad Med J 2014;90:1490154
(2)Jolobe OMP
Bridging the communication gap between healthcare providers and patients'
advocates
Brit J Hosp Med 2012;73:654
(3)Jolobe OMP
The abbreviated patient-held health record: bridging the communication gap
Brit J Hosp Med 2012;73:234
(4) Jolobe OMP
Can phrmacists help prevent adverse drug ineractions from newly prescribed
drugd
Br J Hosp Med 2009;70:360

Re-Freud's unconscious mind and the "EBM World"

I would like to thank the author on a thoughtful reflection on the
"unconscious mind" and would like to comment on its relevance in modern
medicine especially psychiatry and allied fields.

Understandably concepts like the "drive theory" or "defence
mechanisms" do not lend themselves to critical appraisal in "Evidence-
based Medicine" terms easily but that in it should not detract from their
usefulness in everyday clinical practice. "Unconscious mind", "drive
theory" and other classic Freudian concepts belong to the set of
hypotheses whose validity might be difficult to prove, but nevertheless
whose utility is unquestionable. Such concepts provide an extremely useful
conceptual framework for clinicians to make sense of hugely complex and
nuanced human behaviour- both "healthy" and "pathological".

While helpful to all medical specialities, they are especially
relevant to mental health clinicians working with patients who do not
easily fit into established diagnostic categories or have significant
personality dysfunction.

Like with other medical theories, with greater knowledge and
technological advancements they can be suitably modified and refined to
the benefit of our patients. Just like any other hypothesis, Freudian
concept of "Unconscious mind" has its strength and limitations and by its
judicious use in the right context we would maximise its clinical utility.

I feel we as clinicians would be doing us and our patients a dis-
service if we remain totally ignorant about it or rigidly dismiss it
outright for not being easily compatible with classic "Evidence-based
Medicine".

Re:Avoiding Burnout

Dear Editor
Our editorial was triggered by a PMJ paper showing that in a study carried
out in the US, 76% of first year doctors exhibited burnout. We quoted
other evidence that burnout may occur surprisingly early in careers and is
not necessarily related to seniority. We know that jobs which require
daily face to face interaction with people who are distressed or
challenging lead to high levels of burnout. Sadly it is those who are
most empathetic who become emotionally exhausted most quickly. We also
know that isolation, overwork, lack of sleep and lack of expertise all add
to the risk of burnout. New doctors should not have to cope with all of
those at once. There is evidence from the GMC's annual National Trainee
Survey (and before that the London-wide Point of View Survey) that over
the past 16 years the proportion of new doctors who feel stressed, bullied
or sleep-deprived has steadily reduced. We are not aware of any evidence
suggesting it has got worse, though stresses may well have been
transferred to those higher up the career ladder. Big problem is
dependence on doctors in training to deliver service. Not a problem as
such, but it is when service demands mean working under stress and without
colleagues and supervision. Unsupervised work provides experience but
cannot be considered as training. Working in teams, even if the membership
of the teams changes, mitigates against isolation and provides supervision
for the junior members.
Diana Hamilton-Fairley. Elisabeth Paice

We agree that delirium is serious, and more structured instruments
are needed for providers of multiple specialties to detect delirium in
multiple health care settings. While we have no experience on the I-AGeD
in our emergency departments, we note that caregivers often are not
available at the time of emergency presentation. Also, we find veracity of
caregiver reports highly dependent on relationship and time spent with the
patient. Ideally, providers should have access to tools that use only
patient-level information in addition to tools that use caregiver
information for diagnosing delirium.

In their interesting study Suffoletto et al [1] examined delirium
recognition by emergency physicians. Trained researchers identified
delirium in 24/259 (9%) of emergency room older patients. Diagnosis was
based on CAM -ICU criteria, Richmond Agitation and Sedation scale and an
interview with the surrogate. By contrast, emergency physicians recognised
delirium in only 8/24 cases and misidentified delirium in seven cases.
Delirium is a serious condition, and it is associated with poor outcome.
Recognition of delirium is important and might improve patient outcomes.
Study findings are in line with previous studies that showed there is room
for improving delirium recognition,

We have looked at this problem recently and developed and validated a
new screening instrument, the Informant Assessment of Geriatric Delirium
scale (I-AGeD) [2]. It is a 10 items caregiver baser questionnaire. The I-
AGeD was validated in elderly patients admitted to a geriatric wards of
two general hospitals. Average age in the construction cohort was 86,4
yr, 51/88 suffered from dementia and delirium was found in 31/88. In two
validation cohorts, sensitivity and specificity ranged from 70-88.9% and
66.7 -100%.

Given the present demographics, the incidence of delirium will rise,
and recognition of delirium may be difficult, especially in patients with
dementia. Training physicians outside the field of geriatrics on this
issue is important. We think that an caregiver based screening instrument
might be an efficient way to improve early and fast recognition of
delirium in geriatric patients.

I applaud Paice and Hamilton-Fairley's call for better work schedules
and supervision, but burnout seems to increase with seniority and probably
reflects more fundamental problems. Achieving even the aims mentioned may
be more difficult than the authors suggest.

They note that instant teams function well in the airline industry
but link this statement to a paper which referenced stability as one
defining factor for well-structured teams1. The questionnaire to identify
team membership in that study across all types of hospital employees
didn't ask about (or exclude) stability in the 'well-structured' teams
correlated with weaker stressor-strain relationships. One criterion
defining membership of a well-structured team was 'regular team meetings',
which surely implies at least moderate stability. 'Ensuring that there is
a leader, shared goals, well-defined roles, and mutual respect' are indeed
important but stability is also necessary for most medical teams. Instant
teams might function on airline flights but such teams in Medicine present
serious problems for care of patients as well as for clinical supervision
and appraisal of new doctors.

If it 'really isn't that hard' to avoid damaging work schedules, we
might ask why they are still so common and why Deaneries and other bodies
haven't been able to stop them. One answer is, presumably, that the
profession has progressively lost influence in many Trusts. The experience
of 'hospital-at-night' in many Trusts is very different from the original
concept. Too often, a few doctors (without the other help provided in
exemplar sites) are responsible for large numbers of patients. There is
evidence of unacceptable demands on many medical registrars for whom
effective supervision of newer doctors is not possible2

It's interesting that stress and dissatisfaction appear to be
increasing despite overall reduction in working hours. Preparing new
doctors to cope with clinical reorganisations, NHS instability and
employers' attitudes to medical staff is a significant problem. In truth,
fewer doctors in both hospital and general practice seem to want to work
at night and the NHS doesn't yet know how to cope with that. I wonder if
current levels of burnout and dissatisfaction reflect a deeper malaise for
which we might need a different type of conversation?